Pulmonary Emergencies Flashcards
Causes of Upper Airway Obstruction
Foreign body
Tongue
Swelling/edema
Upper Airway Obstruction Etiology
Foreign body Retropharyngeal abscess Angioedema Head and neck trauma Swelling/edema from inhalation injuries Epiglottitis Croup Tonsillitis Peritonsillar abscess Ludwig's angina
Types of Foreign Body Obstruction
Incomplete
Complete
Where does the retropharyngeal space extend from and go to?
Base of the skull to the tracheal bifurcation
Etiology of Retropharyngeal Abscess in Children
Lymph node that drains the head and neck
Etiology of Retropharyngeal Abscess in Adults
Penetrating trauma
Infection in the mouth/teeth
Lymph nodes that drain the head and neck
Signs and Symptoms of a Retropharyngeal Abscess
Fever Dysphagia Neck pain Limitation of cervical motion Cervical lymphadenopathy Sore throat Poor oral intake Muffled voice Respiratory distress Stridor (children) Inflammatory torticollis
Work Up of Retropharyngeal Abscess
Lateral soft tissue X-ray of the neck during inspiration
CT scan of the neck: “gold standard”
Treatment of Retropharyngeal Abscesses
Immediate ENT consult
Surgical I&D
IV hydration
IV antibiotics
Antibiotics for a Retropharyngeal Abscess
Clindamycin
Ampicillin-sulbactam (Unasyn)
Complications of a Retropharyngeal Abscess
Extension of infection into mediastinum
Pleural or pericardial effusion
Upper airway asphyxia
Sudden Rupture: aspiration pneumonia or widespread infection
Define Angioedema
Subdermal or submucosal swelling
Describe the Swelling in Angioedema
Diffuse
Non-pitting
Assessment of Angioedema
Rapid assessment of airway
Close monitoring
What areas of the body does angioedema generally affect?
Face Lips Mouth Throat Larynx Extremities Genitalia Bowel
Etiology of Angioedema
Mast cell mediated
Bradykinin mediated
What medications does mast cell mediated angioedema respond to?
Epinephrine
Glucocorticoids
Antihistamines
What conditions or medications does bradykinin mediated angioedema occur secondary to?
ACE-inhibitors
Hereditary angioedema
Treatment of Allergic Angioedema
Intubation if signs of respiratory distress
Epinephrine (0.3 mg IM)
Glucocorticoids
Diphenhydramine (25-50 mg IV)
Treatment of ACE Inhibitor Induced Angioedema
Intubation if signs of respiratory distress
Discontinue offending drug
If severe or no improvement in 24 hours: antihistamines, glucocorticoids, C1 inhibitor therapy
Treatment of Hereditary Angioedema
Intubation if signs of respiratory distress
C1 inhibitor if available
Bradykinin receptor antagonist
Define Anaphylaxis
Acute, potentially lethal, multi system syndrome from the sudden release of mast cells and basophils into the circulation
Presentation of Anaphylaxis
Sudden onset urticaria Angioedema Flushing Pruritus Hypotension
Treatment of Anaphylaxis
Epinephrine
Airway Management in Anaphylaxis
Immediate assessment for wheezing, stridor, and difficulty breathing
Intubation if marked stridor or respiratory arrest
Treatment of Anaphylaxis
Assess airway IM epinephrine O2 via nonrebreather (patent airway) 2 large bore IVs NS rapid bolus via IV (1-2L) Consider: albuterol nebulizer, H1 blocker, H2 blocker, methylprednisolone
Usually Medications Given in Anaphylaxis
Epinephrine H1 blocker: diphenhydramine H2 blocker: ranitidine Glucocorticoid: solu-medrol Albuterol nebulizer Possible vasopressors
Possible Assessment Findings in Head and Neck Trauma
Gurgling
Snoring
Stridor
Wheezing
Define Gurgling
Pooling of liquids in the oral cavity or hypopharynx
Define Snoring
Partial airway obstruction at the pharyngeal level from the tongue
Define Stridor
Inspiratory: obstruction at the level of the larynx
Expiratory: obstruction at the level of the trachea
Define Wheezing
Narrowing of lower airways
Important Aspect in Head and Neck Trauma
Securing the airway
Avoid nasotracheal intubation
Stupor/Coma and Airway
Inability to protect airway due to lack of gag reflex
Define Stupor
Lack of critical cognitive function and level of consciousness wherein a sufferer is almost entirely unresponsive and only response to base stimuli such as pain
Define Coma
State of unconsciousness lasting more than 6 hours in which a person cannot be awakened; fails to respond normally to painful stimuli, light or sound; lacks a normal sleep-wake cycle; and does not initiate voluntary actions
Define Pneumothorax
Accumulation of air in the pleural space
Describe a Spontaneous Pneumothorax
Pneumothorax that occurs without a precipitating event in a person without lung disease
Risk Factors for a Spontaneous Pneumothorax
Men Age: 20-40 Thin build Smokers Family history Marfan syndrome Prior episode
Presentation of a Spontaneous Pneumothorax
Sudden onset of dyspnea and pleuritic chest pain
Often occurs at rest
Physical Exam Findings in Pneumothorax
Decreased chest excursion Decreased breath sounds on the affected side Hyperresonant to percussion Possible subQ emphysema Hypoxemia Suspicion of tension pneumothorax
When should one suspect a tension pneumothorax?
Labored breathing Tachycardia Hypotension Tracheal shift JVD
Treatment of Pneumothorax
Supplemental O2
Needle decompression
Chest tube placement
Presentation of Acute Pulmonary Edema
Dyspnea Frothy pink sputum Pedal edema Ascites Rales Wheezing HTN Hypoxemia Restlessness Tachycardia Look ill Cold sweat
Types of Acute Pulmonary Edema
Cardiogenic
Non-cardiogenic
Acute Causes of Cardiogenic Pulmonary Edema
Ischemia Acute severe mitral regurgitation Acute aortic regurgitation Hypertensive crisis secondary to bilateral renal artery stenosis Stress induced cardiomyopathy
Chronic Causes of Cardiogenic Pulmonary Edema
Decompensated systolic CHF
Decompensated diastolic CHF
Left ventricular outflow tract (LVOT) obstruction
Valvular heart disease
Noncardiogenic Pulmonary Edema
ARDS Altitude Neurogenic Narcotic overdose Pulmonary embolism Eclampsia Transfusion related injury Salicylate overdose
Etiology of ARDS
Sepsis Acute pulmonary infection Trauma Inhaled toxins DIC Shock lung Freebase cocaine smoking Post CABG Inhalation of high concentrations of O2 Acute radiation pneumonitis
Treatment of Cardiogenic Acute Pulmonary Edema
O2 Treat underlying cause Ischemia Valvular disease Treat arrhythmias
Treatment of Noncardiogenic Acute Pulmonary Edema
O2
Treat underlying cause
Likely intubation and mechanical ventilation with PEEP
Diuretics
Treatment of Generalized Acute Pulmonary Edema
Assess the airway and stability of the patient
Furosemide (Lasix) if hemodynamically stable
Supplemental O2
Treat underlying cause
Pathophysiology of Asthma
Inflammation of the airways with an abnormal accumulation of eosinophils, lymphocytes, mast cells, macrophages, dendritic cells, and myofibroblasts
Reduction in airway diameter caused by smooth muscle contraction, vascular congestion, bronchial wall edema, and thick secretions
Things to Beware of During Assessment of Acute Asthma
Use of accessory muscles of respiration Fragmented speech Orthopnea Diaphoresis Agitation Low blood pressure Severe symptoms that fail to improve
Findings Demonstrating Impending Respiratory Failure in Acute Asthma
Inability to maintain respiratory effort and rate
Cyanosis
Depressed mental status
Severe hypoxemia despite high flow O2 via non-rebreather
Assessment of Acute Asthma
Measure peak flow Supplemental O2 Establish IV access Frequent reassessment ABGs & CXR not useful initially
How does peak flow help in the assessment of an acute asthma patient?
Provides an objective measurement as to the severity of airflow obstruction
When should you measure peak flow?
Before and after each nebulizer or MDI treatment
Medical Therapy for Acute Asthma
Albuterol Ipratropium bromide Methylprednisolone Magnesium sulfate Epinephrine Terbutaline
Function of Albuterol
Bronchodilator
Function of Ipratropium Bromide
Bronchodilator
With the albuterol = Duoneb
Function of Methylprednisolone (Solu Medrol)
Decreases airway inflammation
When is magnesium sulfate given in an acute asthma patient?
Life threatening exacerbations that remains ever after 1 hour of intense bronchodilator therapy
When is epinephrine given in an acute asthma patient?
Suspected anaphylactic reaction or unable to use inhaled bronchodilators
When is terbutaline given in an acute asthma patient?
Severe asthma unresponsive to standard therapy
What is a COPD exacerbation generally precipitated by?
Viral or bacterial infection
Define COPD Exacerbation
Increase or change in character of usual symptoms of dyspnea, cough, or sputum production
Work Up of a COPD Exacerbation
O2 saturation ABG: severe CXR CBC (+/-) BMP (+/-) BNP (+/-) EKG
What is a CXR assessing for in COPD exacerbations?
Pneumonia
Acute heart failure
Pneumothorax
Pharmacotherapy for COPD Exacerbation
Supplemental O2
Solumedrol (methylprednisolone)
Antibiotics: cover pseudomonas
Inhaled bronchodilators
When would you consider hospital admission for a COPD exacerbation?
Symptoms severe enough to prevent ADLs and IADLs
Failure to respond to initial therapy
High risk co-morbidities
Worsening hypoxemia
What are high risk co-morbidities in a COPD exacerbation?
Pneumonia CHF Arrhythmia Liver failure Kidney failure DM
What is the treatment of impending respiratory failure in a COPD exacerbation?
Intubation
Non-invasive positive pressure ventilation
Define Pulmonary Embolism
Obstruction of the pulmonary artery or branches with clot, tumor, air, or fat
Signs and Symptoms of Pulmonary Embolism
Dyspnea Tachypnea Cough Hemoptysis Syncope Lower extremity edema Cyanosis Diaphoresis Hypotension Rales (+/-) Lower extremity pain or erythema
Risk Factors for Establishing a Pulmonary Embolism
Pregnancy Obesity Prolonged immobilization Hormones: BCPs, HRT, SERMs Cancer Trauma Recent joint replacement surgery History of DVT Autoimmune disease HTN Smoking CHF
Wells Criteria for Pulmonary Embolism
Clinical Signs and Symptoms of DVT
PE Is #1 Diagnosis, or Equally Likely
Heart Rate > 100
Immobilization at least 3 days, or surgery in the Previous 4 weeks
Previous, objectively diagnosed PE or DVT
Hemoptysis
Malignancy w/ treatment within 6 mo, or palliative
Work Up of Pulmonary Embolism
CTA of the chest with PE protocol CXR EKG: sinus tach Echo +/- V/Q scan D-dimer Doppler US of LE
What changes can you see on lead I of an EKG for a pulmonary embolus?
S-waves
What changes can you see on lead III of an EKG for a pulmonary embolus?
Q-waves
Inverted T-waves
Treatment and Stabilization of an Acute PE
Supplemental O2
Hypotensive: fluid bolus, vasopressors
What vasopressors are used to treat an acute PE?
Norepinephrine
Dopamine
Epinephrine
Dobutamine + norepinephrine
Pharmacologic Treatment of Acute PE
Unfractionated heparin (UFH)
Low molecular weight heparin (LMWH)
Fondaparinux
Treatment of Acute PE
Vitamin K agonist should be started same day as anticoagulant therapy
Continue Lovenox until INR is 2.0
Thrombolytics??
Signs and Symptoms of Pneumonia
Cough Fever Chills Pleuritic chest pain Dyspnea Sputum production Mental status changes GI symptoms (N/V/D) Tachypnea Tachycardia Hypoxia Rales, rhonchi, or decreased in area of consolidation
Work Up of Pneumonia
PA and lateral CXR CBC, CMP Blood cultures Sputum for gram stain and culture Pneumococcal and Legionella urine antibody tests
Hospital Admission Pneumonic’s for Pneumonia
PSI
CURB-65
Components of a PSI Score
Age Gender Nursing home resident Neoplastic disease Liver disease history CHF history Cerebrovascular disease history Renal disease history Altered mental status RR 29+ SBP less than 90 mmHg Temp: less than 35 or 39.9+ Pulse: 124+ pH: less than 7.35 BUN: 29+ Sodium: less than 130 Glucose: 249+ Hematocrit: less than 30% pO2: less than 60 mmHg Pleural effusion
Components of CURB-65
C: confusion U: urea (BUN >19 mg/dL) R: RR >30 B: SBP less than 90 or DBP less than 60 65: 65+ years old
Treatment of Pneumonia
Supplemental O2 Intubation or NiPPV if respiratory failure Antibiotics Fluids Antipyretics Albuterol nebulizer (+/-) Incentive spirometry
Most Likely Pneumonia Pathogen
Strep pneumo
Non-ICU Hospital Admission Pneumonia Pathogens
Strep pneumo Respiratory viruses M. pneumoniae H. flu C. pneumoniae Legionella
Antibiotics for Non-ICU Pneumonia Patients
Respiratory fluroquinolone OR antipneumococcal beta-lactam
PLUS
Macrolide
Examples of Respiratory Fluroquinolones
Levofloxacin
Moxifloxacin
Gemifloxacin
Examples of Antipneumococcal Beta-Lactam
Cefotaxime
Ceftriaxone
Ampicllin-sulbactam (Unasyn)
Examples of Macrolides
Azithromycin
Clarithromycin
Erythromycin
Pathogens for Patients Requiring ICU Admission for Pneumonia
S. pneumoniae Legionella Gram-negative bacilli Staph aureus Consider MRSA
Antibiotics for ICU Pneumonia
Antipneumococcal beta-lactam + azithromycin
Antipneumococcal beta-lactam + respiratory fluoroquinolone
Penicillin allergy: respiratory fluoroquinolone + aztreonam
